2011-01-20_HYDROLOGY - M1980244 (2)

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12 -10 -10 07:17 FROM -Colo Div of Water Resources +3038663589 T -508 P.007/008 F -572 ows-61 owarma Contact / Company NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) Please type or print legibly In black or blue Ink S•%Q 6y_ / COLORADO DIVISION OF WATER RESOURCES -1313 SHERMAN ST -RM 821 - DENVER -CO -60203 PHONE; 303 -888 -3531 —FAX: 303466 -3589 Weil Owner's Name, Addeee & Phone Cel v/a Ito / .0, /,+it `F' /1 a, , ,1 v cn' s CD dear b0 Landowner's Neme C 1 49.1.-0 /7/01■Yeeg 67 Please check one and complete as Indicated including contact info: I] Water Well Driller Lloensed In Colorado - Lic. No. O Professional Engineer Registered In Colorado - Reg. No. Q Professional Geologist per CRS 34 201(3) g Other - anyone directly employed by or under the supervision of a licensed drlllor, r+aglatered profesekmel engineer or pro slonai g • logist Address A , 9/ Cit State & Zip , G7V4 (D et) P6.0 Phone 7/ 09^ 4'0 y 1r Fax 7/ ��1 `..? Print Name: Signature: 0e Location: X ___ X /,, Section - Townahlp/ JN MIB, Range DEZW, 77PM County ' -e .c re. Subdivision, Lot, Bik, Pig (as applicable) Site/Property Address ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE FOR OFFICE USE ONLY ._, " MH P ROCESSED BY GPS Location In UTM format (optional): SeI GPS unit to true north, datum NAD83. and use meters for the distance units, DZone 12 or OZone 13. Easting Northing # of Monitoring Hole(s) to be constructed: Estimated Depth <00 Ft., Aquifer Purpose of Monitoring Hole(s) /la✓/ ftV4 wed Anticipated Date of Construction: /62- / 7' "0 Data Notice Submitted: /2-- C 9 to (Must be et least 3 days prior to construction) Dtv. L - WD _ 7i BAs MD DATE ACKNOWLEDGED 12 ' (0 ` ( o CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITE. 1) Notice was provided to the State Engineer at (east 3 days prior to construction of monitoring & observation hole(s). 2) Constriction of the holes) must be completed within go days of the date notice was given to the &trite Engineer. Testing and/or pumping shall not exceed a total of 200 hours unless prior written approval is obtained from the State Engineer. Water diverted during testing shall not be used for beneficial purposes. The owner of rho hole(e) is responsible for obtaining permft(s) and complying wit all rules and regulations pertaining to the discharge of fluids produced during testing. 3) All work must comply with the Water Well Construction Rules, 2 CCR 402-2, Minimum conatruodon standards must be met or a variance obtained. Standard permit application and work report forms are found on the DWR website at hups/Iwww.waseraintexem. Well Construction and Test Reports (GWS31) must be completed for each hole drilled. The licensed contractor or authorized Incfivkluel must submit the completed forms to this Wilco within 60 days Of monitoring hole completion, 4) Unless a well permit is obtained, the hole(s) must be plugged and sealed within ono (1) year after construction, An Abandonment Report (form GWS.9) must be submitted within 60 days of plugging & sealing. The above MH acknowledgement number, owner's °trusttare name, and owners name and address must be provided on all well permit appfcadon(s), wall construction and abandonment reports. 5) The owner of tho hole(s) shall maintain records of water quality testing and submit this date to the State 6ngineer upon request. 6) A MONITORING HOLE CANNOT BE CONVERTED TO A PRODUCTION WATER WL'LL, except for purposes of remsdiation (recovery) or as a permanent dowatering system, If constructed in accordance with the Wator Well Construction Rules and policies of the State Engineer. 7) iF HOLES WILL NOT BE CONSTRUCTED TINDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE, "NO HOLES CONSTRUCTED" ON A COPY OP THE ACKNOWLEDGED NOTICE WITH THE FILE NUMBER AND FAX THE COPY TO THE DN4$ION of WATER RESOURCeO. THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. (Use above space for labels or additional conditions as needed)